1659721496 NPI number — JESSICA D. LEWIS APRN

Table of content: JESSICA D. LEWIS APRN (NPI 1659721496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659721496 NPI number — JESSICA D. LEWIS APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
JESSICA
Provider Middle Name:
D.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659721496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2585 3RD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25703-1642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-697-1396
Provider Business Mailing Address Fax Number:
304-697-2086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 HARBOUR WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-743-1407
Provider Business Practice Location Address Fax Number:
304-743-4516
Provider Enumeration Date:
06/13/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  71360 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1659721496 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0295267 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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